Nonpartison Healthcare

Healthcare is expensive and the insurance that helps pay for provider services is likewise expensive. Increased use of doctors and medical facilities, the demand for the newest technology and expensive medications, and our desire that our ailments be “fixed now” drives up the cost of healthcare.  Defensive medicine is another cost driver as physicians may over test to protect themselves from lawsuits, or duplicate tests when providers do not share results.

What do people really want? From my experience, workers want their employer to provide their

health insurance, and they do not want to be taxed on the costs of those benefits.  Employers

also do not want to be limited on tax-free benefit packages they provide their employees. Other

individuals, often small business owners, want the freedom to purchase “good insurance

coverage” at a reasonable cost for themselves and their families.  They want the freedom to

choose or reject costly benefits like maternity, substance abuse, and unlimited lifetime benefits.

It’s also important for individuals to be able to build a relationship with a physician who will

follow and coordinate any future care needs. We want our doctors to know us.

 

People with financial means may prefer to purchase catastrophic insurance protection, insuring

above an established dollar amount, like $10,000 or $20,000. Using Health Savings Accounts is a

popular choice for those who understand the concept and tax savings, but without

outside funding from an employer, grants, or other source, HSAs would not appear to benefit

those with lower incomes and/or little savings.

 

Concerning the Affordable Care Act (ACA) and the American Health Care Act (AHCA), please note, neither is health insurance—only mandates for insurance carriers, providers, employers and individuals. While the ACA imposed millions of dollars in taxes and fees, it did not make healthcare more affordable, and it did not lower the cost of insurance.  In fact, the ACA raised premiums and decreased benefits from the traditional medical plans prior to ACA.  The ACA attempted to reinvent the wheel for health insurance enrollment and administration, and changed health insurance into a program requiring insurance carriers to cover all pre-existing conditions immediately.  For nondiscrimination, all information is available in English and 15 other languages. Neither the ACA nor the AHCA addresses containing the cost of medical care to control insurance premiums.

When someone says they have ACA or Obamacare, they usually mean they qualified for a subsidy.  Any health insurance, a new or changed plan, effective January 1, 2014 or later is ACA. While advance premium tax credits (APTCs) and enhanced benefits provided through the ACA tremendously helped many to afford insurance, others were hurt by higher premiums and less coverage that required individuals and families to spend thousands of dollars out-of-pocket for their care.  The 2017 mandated maximum out-of-pocket limits are $7150 for individuals and $14,300 for families.  Middle Americans generally do not have that amount of savings to pay for healthcare.

Are more people covered by insurance now?  Yes, but at the same time, many lost the coverage they had because their old plans did not cover newly mandated “essential” benefits. Many new enrollees on the Exchange or Marketplace already had insurance, but either their carrier dropped their plans or they qualified for financial assistance under ACA and had to enroll in an ACA plan.  Others qualified and enrolled for Medicaid under current rules.  NC did not expand Medicaid where assets would no longer be considered when qualifying for aid, but many fell into a hole making too little for a subsidy and yet were ineligible for Medicaid under current requirements.

There is also a new demographic of uninsured. Individuals making over $47,520 (modified adjusted gross income), a couple making over $63,720, or family of 4 making over $97,000 are getting no help toward high premiums.  Individuals between 55 and 64 often can’t afford or won’t pay $1200 to $1500 per month for high deductible coverage, and for families the cost could be $3500, or higher, per month.  Alternatively, people are buying into religious associations that are pooling members’ money to reimburse their future medical claims, and hoping for the best.  This is slightly better than having no coverage, or self-insuring.

What will lower the cost of care?  First, we must be more accountable for our actions concerning our own health, and where we receive care.  Unless it is an emergency, shop around for medical procedures, tests, and medications.  Not every facility and pharmacy charge the same.  Emergency rooms are not intended to be primary care facilities.  There are numerous free-standing clinics with extended operating hours.  For many conditions, proper diet and moderate exercise will manage the disorder as well, if not better than, medications.

What will lower cost of insurance?  The larger the pool of people insured, the less claims will affect the overall pool.  If everyone purchases an insurance plan, the premiums paid by the healthy will offset the claims paid out for the unhealthy.  It’s economics and large numbers.  The ACA mandated coverage for most everyone and tried to enforce the law with minimal IRS penalties.  The AHCA doesn’t mandate you have coverage, but imposes a 30% premium penalty if you enroll without having had continuous coverage, meaning no more than a 63-day gap.  If everyone had coverage, the hospitals and other providers would not need to overcharge those paying for care to cover those who don’t pay for care.

Free market competition typically lowers product or service costs.  However, healthcare is expensive.  Heart bypass surgery may total $170,000, cancer treatments, hundreds of thousands, a hip replacement, $40,000.  Networks of doctors and providers are important in today’s healthcare delivery to control insurance carrier reimbursements to providers.  There are currently three reimbursement levels:  Medicaid, Medicare, and private insurance.  Medicaid reimbursements are the lowest and the reason why many physicians, especially specialists, do not accept Medicaid patients.  Medicare reimbursements are second lowest, and many physicians are not accepting new Medicare patients.  Insurance company reimbursements are the highest, but are negotiated by carriers to control claims expenditures. The newest insurance reimbursement model follows a patient and treatments from start to finish, and physician reimbursement is based more on patient outcome.

One final consideration, practicing medicine is a business.  It starts with a very expensive education, the purchase of expensive medical equipment and liability insurance.  Then there are medical supplies, computers, a building and utilities, staff and their benefits, and other operating costs.  After physicians make the huge time and financial investment necessary to practice medicine, they want to spend their time on patient care, not interpreting regulations and processing forms.

Of course Americans do not want to see anyone needing medical attention to go untreated. That’s why hospitals provide charity care and numerous non-profits and government programs provide money for the needy. With existing charitable programs and a high-risk pool insurance fund, or reinsurance, to protect carrier losses for major healthcare claims, we can insure that people receive the care they need when they need it. Having immediate access to affordable quality care is what people want.  People value their employers who provide insurance coverage.  Employers and individuals depend on insurance agents to explain benefits, recommend plans, and assist with issues after the enrollment. People value a relationship with their physician who is focused on them and their care.  With federal and state collaboration, each state can create programs to provide healthcare services and wellness education to everyone, broadening Americans’ immediate access to quality care.

 

 

 

 

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